Attribution: Kim Eagle, M.D., 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution–Share Alike 3.0 License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
Attribution Key for more information see: Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. }
Kim A. Eagle, M.D. University of Michigan Health System ElectrocardiogramElectrocardiogram Cardiovascular Sequence Fall 2012
Kim A. Eagle, MD Director University of Michigan Cardiovascular Center Grants: NIH, Hewlett Foundation, Mardigian Foundation, Varbedian Fund, GORE Consultant: NIH NHLBI
Electrocardiogram Key Words: Depolarization, repolarization, EKG leads, electrical axis, ST segment shifts Objectives: 1.To learn the nomenclature and classification system for ECG interpretation. 2.To learn the major conduction abnormalities seen on ECG interpretation. 3.To diagnose ischemic heart disease patterns on ECG’s. 4.To become familiar with how structural heart conditions affect ECG findings.
Electrocardiogram The Normal EKG: Outline Electrical Measurement - Single Cell EKG Reference System - Technical Considerations - Sequence of Activation Interpretation - Calibration - Rhythm - Rate - Intervals - QRS Axis - P-waves - QRS - ST-T wave abnormalities
Electrical Measurement Single Cell Key Concepts - Resting state - polarized - Depolarization - Repolarization - Directionality
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 81
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 82
EKG Lead Reference System Unipolar Bipolar Chest Leads
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 83
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 84
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 86
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 85
Magnitude and Direction of Electrical Activity Key Principles: –Electrical force directed at (+) pole of a lead generates upward EKG deflection –Forces directed away from (+) pole generate downward deflection –Magnitude of deflection reflects how parallel the electrical force to lead –Forces directed perpendicular to a lead generate no activity or flat line
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 85
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 87
Sequence of Normal Cardiac Activation
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 87
A Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 89
DE Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 89 (Both Images)
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 90 (Both Images)
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 90
EKG Interpretation: 8 Steps 1.Check voltage calibration 2.Heart rhythm 3.Heart rate 4.Intervals (PR, QRS, ST) 5.Mean QRS axis 6.Abnormalities of P-waves 7.Abnormalities of QRS (hypertrophy, bundle branch block, infarction) 8.ST and T wave abnormalities
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 91
Heart Rhythm Sinus Rhythm Rate > 60 BPM < 100 BPM
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 93
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 94
Electrocardiographic Intervals IntervalNormal Decreased in Increased in PR sec Pre excitation syndrome First-degree AV block (3-5 small boxes) Junctional rhythm QRS < 0.10 sec Bundle branch blocks (< 2.5 small boxes) Ventricular ectopic beat Toxic drug effect (e.g., quinidine) Toxic drug effect (e.g., quinidine) Severe hyperkalemia Severe hyperkalemia QT Corrected Qt a < 0.44 sec Hypercalcemia Hypocalcemia Tachycardia Hypokalemia ( QU interval due Tachycardia Hypokalemia ( QU interval due to U wave) to U wave) Hypomagnesemia Hypomagnesemia Myocardial ischemia Myocardial ischemia Congenital prolongation of QT Congenital prolongation of QT Toxic drug-effect (e.g., quinidine) Toxic drug-effect (e.g., quinidine)
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 95
Atrial Abnormalities Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 97
Ventricular Hypertrophy Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 98
Ventricular Hypertrophy Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 98
Bundle Branch Blocks RBBB Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 99
Bundle Branch Blocks LBBB Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 99
The EKG of Myocardial Infarction Concept of ST elevation vs. Non STE Localization of MI Evolution of EKG changes in MI Concept of Q waves
Scan page 88 LILLY (4.25 transmural) Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 106
Localization of MI Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 104
Localization of MI Anatomic SitesEKG LeadsCoronary Anatomy InferiorII, III, AVFRCA SeptalV 1, V 2 LAD AnteriorV 3, V 4 LAD (distal) AnterolateralI, AVLLCX AnteroapicalV 5, V 6 Any of 3
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 105
Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, Page 103